Controlled biothermotherapy

ABSTRACT

A method for thermotherapy of a biological tissue by determining the temperature at which to heat a target site to be treated to provide a temperature to the site to effect therapy, the temperature above body temperature but below a protein denaturation temperature, as determined by a patient&#39;s experience of a sensation of pain. Thermotherapy is effected in the absence of coagulative effects by providing oscillatory energy at the predetermined temperature.

This application is a division of co-pending U.S. application Ser. No.12/256,057 filed Oct. 22, 2008 which is expressly incorporated byreference herein in its entirety.

A method to determine and control parameters for thermotherapy of abiological tissue to achieve a temperature below that at which proteindenaturation occurs. Assessing the time at which a patient expresses asensation of pain when exposed to an elevated temperature, relative tobody temperature, accurately precludes exposing the patient to atemperature at which proteins denature during thermotherapy.

The method encompasses the use of any type of thermotherapy including,but not limited to, laser therapy, photodynamic therapy, andtranspupillary therapy. Therapy refers to any amelioration ofpathological effects, including lessening severity, lessening symptoms,etc. Complete treatment efficacy is included, but is not required.

Laser coagulation therapy has long been used to treat retinal andchoroidal disease (Ophthalmic Surg. 13 (1982) 928). Laser coagulationproduces its effect when ocular tissues, such as retinal pigments and/orfluids, absorb light energy (visible, infrared) and are exposed toincreased temperatures to result in protein denaturation, that is,coagulation. As a result, laser coagulation is a tissue destructivemethod. It therefore cannot be performed over the center part of thefovea, which is the most visually sensitive part of the retina, becausethese tissues will be permanently damaged and visual function will belost. Laser coagulation has been effectively used in peripheral portionsof the retina and choroid to close abnormal vessels, for example, as aresult of diabetes or subretinal extra-foveal neovascularization. Insome cases, however, laser coagulation can lead to vision loss becauseof growth of the laser spot and/or scar over time, or because subretinalneovascularization causes bleeding, or incites new vessel growth.

Photodynamic therapy (PDT) uses laser light along, with aphotosensitizer injected intravenously, to achieve its effect, forexample, vascular occlusion. The photosensitizer, upon light activation,releases in the vessel singlet oxygen that damages the vessels andcauses platelet aggregation and blood clots. PDT is more protective tothe retina than laser coagulative and can be used over the fovea.However, it requires multiple treatments to close abnormal vessels, andproduces a scar under the fovea and reduces vision over time(Ophthalmology 107 (2000) 29).

Transpupillary thermotherapy (TTT) has been used to treat wetage-related macular degeneration (ARMD), which exhibits abnormalsubretinal vessels (Retina 25 (2005) 1046; Retina 23 (2003) 378); Retina23 (2003) 371, and U.S. Pat. No. 6,887,261. It had been thought thatlaser light in the infrared wavelength applied over a prolonged periodcould produce a hyperthermic effect without coagulating the retina, butin practice it was not possible to use the standard treatment parametersadvocated by the manufacturer to prevent destructive coagulative lasereffects. Because of the variability in the amount of ocularpigmentation, the same energy would produce coagulation in a pigmentedarea and have no effect in non-pigmented areas. There was also no way tonon-invasively measure the temperature of the retina or the choroid.

Each of laser coagulation, PDT, and TTT lack a reliable method tonon-invasively measure temperature inside the tissue to be treated.Therefore, the temperature needed to safely and predictably achieve thedesired therapy could not readily be determined.

The disclosed method employs a relationship between the patient'sexpression of a sensation of pain when exposed to an elevatedtemperature, relative to body temperature, and the temperature increaseupon application of thermal energy to achieve a desired therapeuticeffect, in the absence of a detrimental protein denaturation effect, asreferred to as a coagulative effect.

The patent or application file contains at least one drawing executed incolor. Copies of this patent or patent application publication withcolor drawing(s) will be provided by the Office upon request and paymentof the necessary fee.

FIG. 1 shows pre-operative optical coherence tomography (OCT) of patient1.

FIG. 2 shows post-operative OCT of patient 1.

FIG. 3 shows pre-operative OCT of patient 2.

FIG. 4 shows post-operative OCT of patient 2.

FIG. 5 shows pre-operative OCT of patient 3.

FIG. 6 shows post-operative OCT of patient 3.

FIG. 7 shows post-operative OCT of patient 3.

FIG. 8 shows pre-operative OCT of patient 4.

FIG. 9 shows post-operative OCT of patient 4.

FIG. 10 shows pre-operative OCT of patient 5, right eye.

FIG. 11 shows post-operative OCT of patient 5, right eye.

FIG. 12 shows pre-operative OCT of patient 5, left eye.

FIG. 13 shows post-operative OCT of patient 5, left eye.

As shown in Table 1 below, measuring the time at which the patientexpresses a sensation of pain when exposed to elevated temperatures,relative to body temperature, accurately precludes exposing the patientto a temperature at which proteins denature. Data are from a normalindividual immersing a finger in water at the stated temperature andduration, and recording a relative subjective sensation of pain.

TABLE 1 EXPOSURE TIME WATER TEMPERATURE BEFORE WITHDRAWAL SENSATION 140°F. = 60° C. Immediate strong pain 130° F. = 54.4° C.  7 seconds pain120° F. = 48.9° C. 15 seconds pain 115° F. = 46.1° C. >7 min warmth 110°F. = 43.3° C. >7 min warmthFrom Table 1, the sensation of pain occurred at a temperature aboveabout 46° C. When a biological cell is exposed to a temperature of about43° C., it produces heat shock proteins (HSP), which are proteins thatprotect biological cells against adverse agents and effects (e.g.,oxidative agents, agents that result in chemical and/or metabolicstress, etc.). When a biological cell is exposed to a temperature ofabout 60° C., its proteins denature, and protein denaturation elicits animmediate and strong pain sensation.

Various treatment methods have been explored to reduce macular edemaand/or central macular thickness (CMT). Treatment with intravitrealinjections of bevacizumab (IVB) alone, or in combination with invitrealinjections of triamcinolone acetonide (IVT), or macular photocoagulationhave not produced satisfactory results. As described in Example I below,only a transient reduction in central macular thickness was achieved inall groups, lasting up to only 6 weeks. Thus, a method for reducingmacular edema and/or CMT is needed.

In one embodiment the method is used to reduce undesirable cellproliferation at various anatomical and/or physiological sites, termed atarget tissue or target cells. A known by a person of ordinary skill inthe art, a tissue is a organization of cells. In one embodiment, themethod is used in the eye to reduce cell proliferation in the choroid,retina, and/or lens capsule. In one embodiment, the method is used toselectively trigger apoptosis in target cells, such as cells that areheat sensitive, abnormal, immature, and/or growing, while leaving normalcells unaffected. For example, when used in the eye, the method mayselectively damage abnormal cells in the retina while leaving normalretinal cells and optic nerve cells undamaged.

The method may also render normal cells less sensitive to metabolicdamage and oxidative stress by inducing HSP production. In oneembodiment, the method thermally and optionally, chemically, treatscells at anatomical and/or physiological sites to induce apoptosis, orimpede cell multiplication, without causing cellular proteindenaturation.

The method creates, in the target tissue, hyperthermia; i.e., atemperature elevated over body temperature, thus a temperature greaterthan about 37° C., but less than about 60° C., which is the temperatureat which protein denaturation occurs. In one embodiment, the methodcreates hyperthermia in the target tissue of greater than about 37° C.,but less than about 46° C., to facilitate HSP production and/or otherhyperthermic effects.

The method minimizes inhibits selective cell growth and/orproliferation.

In treating macular edema, a temperature is selected based upon thepatients specific tolerance for pain. In subsequent thermal treatments,the temperature is maintained below the selected temperature duringlaser therapy to inhibit cell growth and reduce edema.

In one embodiment, the method uses a patient's subjective evaluation ofhis/her own pain threshold as a real-time indicator of temperature ofthe tissue. A pain threshold temperature is determined that is abovebody temperature but below a temperature at which protein denaturationis initiated. By maintaining the temperature below the temperature atwhich the patient experiences a sensation of pain, the temperaturerequired for a beneficial effect without protein denaturation and tissuedamage is achieved.

Beneficial effects of thermotherapy include release of HSP andinhibition of cell division. For example, levels of the HSP Hsp27 andαB-crystallin in C6 rat glioma cells that had been heated at 43° for 30min, with subsequent culture at 37° C. for 16 h, were markedly increased(Cell Stress Chaperones 4 (1999) 94; Biochem Biophys Res Commun 26(2002) 854; J Biol Chem 275 (2000) 4565; and J Cell Physiol 166 (1996)332). HSP such as HSP27 and α-crystallins also play an important role inthe resistance to anticancer drugs); protect lens epithelial cells fromapoptosis (J Biol Chem 275 (2000) 3682; Breast Cancer Res Treat 111(2008) 411); J Biol Chem 276 (2001) 16059); provide protection againstTNFα-mediated cell death and other types of oxidative stress (EMBO J 15(1996) 2695); participate in regulating cell proliferation (Cancer 77(1996) 352); maintain cytoskeleton integrity (J Neurosci Res 66 (2001)59); protect retinal pigment epithelium (RPE) from susceptibility tooxidative stress (Mol. Vis. 13 (2007) 566); protect retinal neurons fromenvironmental and/or metabolic stress damage (Mol. Vis. 9 (2003) 410);play a role in pathophysiology of diabetic complications (Arch BiochemBiophys. 444 (2005) 77); defend against dysregulated proteins (JNeurosci Res 86 (2008) 1343); and protect against ischemic injury(Circulation 96 (1997) 4343). Point mutations in the αA-crystallin genecause congenital human cataracts (J Biol Chem 283 (2008) 5801). Lack ofα-crystallins accentuated retinal degeneration in chemically inducedhypoxia in vivo (Exp Eye Res 86 (2008) 355).

Thermotherapy performed by laser irradiation, at non-coagulative orlow-level laser light, has an anti-inflammatory effect on tissues(Lasers Surg Med 40 (2008) 500; Inflammation 31 (2008) 189; and PhotomedLaser Surg 26 (2008) 19), and prevents scar formation (Lasers Surg Med40 (2008) 443; Lasers Surg Med 28 (2001) 168; and Lasers Surg Med 40(2008) 159).

In one embodiment, the method enhances penetration of medicaments intotissue. It is known that thermotherapy enhances penetration ofmedication into tissues and thereby enhances the effect of thesemedications (Lasers Surg Med 40 (2008) 468). Hyperthermic effectsenhance efficacy of a medication's effect on tissues by increased tissuepenetration and reabsorption of preexisting intra- and inter-cellularfluid which otherwise causes tissue edema. Thermotherapy increases bloodcirculation, which also enhances drug delivery to the tissue byexpanding the capillaries and vasculature at the site of interest, thusincreasing blood flow to the site.

In one embodiment, the method uses an energy emitting device toselectively heat tissues at a desired site to a temperature that killsthe cells without causing protein denaturation in the cells. Any thermalsource may be used. In one embodiment, light is used as a heat source.In one embodiment, ultrasound is used as a heat source. In oneembodiment, heating occurs with chemical treatment to change a cellphysical characteristic to thus cause cell death or impede cellmultiplication. Such devices with and without chemical treatment aredisclosed in U.S. Pat. No. 6,887,261.

In one embodiment, the method uses an energy emitting device and apositioning device that is adapted to position the energy emittingdevice relative to the cells at the site to be treated. In embodiments,the positioning device aims and/or manipulates the energy emission fromthe energy emitting device. For example, the positioning device mayincludes a slit-lamp, ophthalmoscope, microscope, fiber optic conduit,reflector, mirror, lens, camera, and other imaging systems includingmagnetic resonance imaging (MRI) and computed tomography (CT).

In one embodiment, the method uses a laser to effect hyperthermia in thetissue at the desired anatomical and/or physiological site. Suitablelasers as a source of energy (heat) include all visible light sourcesthat are capable of producing thermal effect from 400 nm to 750 nm, allelectromagnetic radiation sources that are capable of producing thermaleffect from 750 nm to 1.7 M, and ultraviolet light sources from about280 nm to 400 nm, using an individual wave length or a collection ofwavelengths. Alternatively, a source of energy can be ultrasound,microwave, or other electromagnetic radiation that will sufficientlyheat to thermally treat cells as described. In one embodiment, the poweroutput of, for example, a laser, is adjustable to the desired level from1 mW to 1.5 W.

The method uses an oscillating energy source. This achieves therapeutictemperature levels in the tissue, without causing protein denaturationand thermal coagulation of the tissue, resulting in tissue burning andnecrosis. In contrast to the inventive method, ocular tissue treatedwith TTT uses a stationary laser that is focused on a single large areathat treats the entire area and delivers constant energy over the entirespot.

The tissue, or portion of tissue, is exposed to the energy source thatis provided in an oscillatory manner. Oscillation describes a changinglevel of energy being received by the target tissue. In one embodiment,the changing level in the energy received by the target tissue isdefined by the maximum and minimum energies received, and/or theperiodicity, e.g., the time interval between consecutive maximum energylevel being received by the target tissue. In one embodiment, the outputof the energy source is moved relative to the target tissue. Forexample, in the case of a laser, the laser beam is moved over the targetarea such that no point in the target area receives constantillumination.

In one embodiment, oscillation is achieved by pulsing the energyemission. In one embodiment, oscillation is achieved by a combination ofmoving the emission of the energy source and intermittently applyingenergy to the target tissue. In one embodiment, the maximum energy inthe target tissue is less than or equal to the pain sensation thresholdenergy level. For example, during oscillatory thermotherapy, the maximumenergy directed to the target tissue is less than or equal to the energylevel which elicited a pain response in the particular patient.

In one embodiment, oscillation can be achieved by a hand heldmanipulator. In one embodiment, oscillation can be achieved by anelectromechanically movable manipulator with an adjustable controlsystem to control the extent and direction of energy emission, such asby adjusting raster form, right and left traverse, up and down traverse,size and/or shape of energy emission beam such as semicircular orcircular, and/or motion. In one embodiment, oscillation can be achievedby a pulsed laser. A pulsed laser can be adjusted to cover the entiretarget area of tissue, or can use a shotgun approach with areas ofoverlapping in raster, or circular fashion, or random fashion over thetarget area of tissue. In one embodiment, oscillation can be achievedusing a combination of motion induced mechanical and pulsing emission.In one embodiment, a timer that emits an audible and/or visual signal toindicate the time elapsed to control the degree of energy needed may beused. In one embodiment, oscillatory thermotherapy is controlledremotely, e.g., via the Internet.

In one embodiment, a system is provided with controls to adjust the spotsize of energy emission, e.g. light, on the desired target area. In oneembodiment, the spot size of energy emission ranges from about 0.05 mmto about 8 mm or more by using, e.g., an aperture, a lens, a mirror,etc.

In one embodiment, the spot size ranges from about one third to aboutone half the size of the target site, e.g. lesion, to be treated. In oneembodiment, the target tissue is exposed to oscillatory energy, e.g.,moving or intermittent energy, for up to about 1 minute to about 7minutes, or as needed.

One embodiment is a test mode, in which the maximum energy emission tobe applied to a target tissue is pre-determined by assessing exposure toa non-target tissue (e.g., normal retina, normal choroid, etc.). In thistest mode embodiment, the laser or other energy source is applied in anon-oscillatory mode for about 10 seconds up to about 30 seconds at asetting such that the patient does not experience a sensation of pain.In one embodiment using the test mode, the laser is applied in anon-oscillatory mode for about 10 seconds to about 20 seconds withoutthe patient experiencing a sensation of pain. In one embodiment usingthe test mode, the spot size is from about 100 μm to about 4000 μm. Inthis way, the energy setting that does not result in a sensation of painand that does not produce any coagulative necrotic tissue damage to thetarget tissue is determined. Thus, when the target tissue is thentreated with oscillatory energy at or below the pre-determined energylevel, the practitioner is assured that no protein coagulation and/ordenaturation will occur in the target tissue. This is because the tissuetemperature is reduced during energy oscillation, e.g., with anoscillation of about 1/sec or less up to an oscillation of about 100/secor more. Oscillating thermal energy provides sufficient tissue coolingby, e.g., thermal conduction, reflection, or blood circulation, whilestill providing sufficient heat to induce beneficial effects, such asHSP production, etc.

In one embodiment, the target tissue is exposed to oscillatory energy ina pre-heat mode prior to exposure to oscillatory energy in a treatmentmode. In one embodiment, the tissue is exposed to laser energy for about0.5 minute to about 2 minutes prior to treatment with oscillatoryenergy. In one embodiment, when the tissue to be treated is about 200 μmthick to about 250 μm thick, pre-heat treatment occurs for about 1.5minutes (90 seconds). In one embodiment, when the tissue is thicker than250 μm, for each additional 100 μm in thickness, the duration of thepre-heat treatment is increased about 1.5 times. For example, a tissuethat is about 450 μm thick is pre-heated for about 4.5 minutes beforetreatment for about 4.5 minutes. In one embodiment, the amount of timeand oscillatory energy to which the tissue is equal to the amount oftime and energy that was used to pre-heat the tissue. In embodimentswhere a biocompatible dye is employed, the dye may be injected orotherwise provide during and/or following the pre-heat treatment.

The extent of treatment, which as described above includes any of energyoutput, duration of exposure to energy, size of target spot, parametersof oscillation of energy exposure, etc., are varied depending on severalfactors. One factor accounts for the volume of fluid in the targettissue. For example, an edematous tissue may require increased treatmentto achieve a desired effect relative to a non-edematous tissue; this maytake the form of increased energy output, increased duration of exposureto energy, etc. One factor accounts for the presence and/or extent ofpigmentation in the target tissue. Pigmentation affects the amount ofenergy in the form of light that is absorbed by the tissue; pigmentedtissues more readily absorb light energy and thus exhibit a largertemperature increase than a less pigmented tissue for a given energyemission. For example, a pigmented tissue will require less treatmentthan a non-pigmented or less pigmented tissue; this may take the form ofdecreased energy output, decreased duration of exposure to energy, etc.All of these factors are taken into consideration when a patientexpresses pain sensation with a given energy and time of exposure.

In one embodiment, one or more additional components that enhanceabsorbance of the thermal energy are included with the method. In oneembodiment, a device to provide the additional components to the targetsite is used. The device can be unitary with or separate from the energyemitting device. In one embodiment, the energy emission used to heat thetissue may be the same or different than the energy source used toactivate the additional component, for example, by emitting light at thesame or different wavelength. In one embodiment, the additionalcomponent is a biocompatible dye, examples of which include but are notlimited to indocyanine green (ICG), vorteporfin, rose bengal, liassaminegreen, etc. In one embodiment, the biocompatible dye is indocyaninegreen. The dye lowers the amount of energy needed for therapy, thusdecreasing damage to the normal adjacent tissue while providing therapyto target tissue. In one embodiment, the energy emitting device can becontrolled to direct energy, e.g. light, onto the target site toactivate a dye present at the target site cells to alter at least onephysical characteristic of the tissues/cells at the target site. In oneembodiment, a systemic dye, e.g. a photosensitizer, can be used toabsorb light energy and increase the temperature at the location and/orproduce a limited additional photodynamic effect inside a vessel, asdescribed in U.S. Pat. No. 6,936,043.

For example, the dye ICG may be used with oscillatory thermotherapy. Thedye may be introduced, e.g. injected, before, during, or afteroscillatory thermotherapy. The dye may be activated before, during, orafter oscillatory thermotherapy. In one embodiment, injecting ICG or anyother appropriate dye, during oscillatory thermotherapy enhances athermal effect because the dye in the vessel at a target site absorbsthe energy, which facilitates selective apoptosis of immatureendothelial cells without coagulating adjacent normal tissue.

ICG is known in the art and used in ophthalmology and cardiology forangiography of the back of the eye and for cardiac function,respectively. Specifically, ICG has been used to enhance coagulation ofportions of the eye. ICG absorbs at a wavelength between about 800 nmand about 810 nm, and fluoresces at a wavelength between about 820 nmand about 830 nm, as described in U.S. Pat. Nos. 2,895,955 and6,887,261.

In one embodiment, the method is performed in the eye. When a choroidalvessel is the target site, it can be closed or altered more rapidly,and/or at lower power levels, than retinal vessels. Thus, treatment ofchoroidal neovascularization in ARMD is achieved while simultaneouslyprotecting retinal vessels.

In one embodiment, before, during or after the energy emitting device iscontrolled to heat the cells in the manner described above, aphotosensitizer is provided at a target site, e.g., retina. In oneembodiment, the photosensitizer is administered locally, e.g., byinjection. In one embodiment, the photosensitizer is administeredsystemically. Upon thermally treatment of retinal tissues by energy,e.g. light, emitted from an energy emitting device, the energy emittingdevice is controlled to activate the photosensitizer, e.g., by emittinglight having a wavelength that activates the photosensitizer at thetarget site, e.g., absorbed by, or located within or adjacent to thetarget site. In one embodiment, OTT is performed for some treatmentperiod, e.g. one half of the entire treatment period, followed byintroduction of a dye, e.g. ICG, and OTT in the presence of dye isperformed for the remaining treatment period. In one embodiment, PDT asdescribed in U.S. Pat. No. 6,936,043 is performed in conjunction with anoscillating energy source.

In one embodiment, additional agents may be included in the method.These additional agents may be locally and/or systemically provided.Examples of such agents include, but are not limited to,anti-inflammatory agents, steroids, non-steroidal anti-inflammatorydrugs (NSAIDS), anti-vascular endothelial growth factor (VEGF) agents,anti-platelet derived growth factor (PDGF) agents, anti-proliferativeagents, metalloproteinase inhibitors, and/or penetration enhancingagents. NSAIDs selectively enhance HSP production and thus theiradministration can be controlled to achieve a desired effect using thedisclosed method.

Examples of such additional agents include, but are not limited to, thefollowing: colchicine; a steroid such as triamcinolone (Aristocort®;Kenalog®), anacortave acetate (Alcon), betamethasone (Celestone®),budesonide Cortisone, dexamethasone (Decadron-LA®; Decadron® phosphate;Maxidex® and Tobradex® (Alcon)), hydrocortisone methylprednisolone(Depo-Medrol®, Solu-Medrol®), prednisolone (prednisolone acetate, e.g.,Pred Forte® (Allergan), Econopred and Econopred Plus® (Alcon), AK-Tate®(Akorn), Pred Mild® (Allergan), prednisone sodium phosphate (InflamaseMild and Inflamase Forte® (Ciba), Metreton® (Schering), AK-Pred®(Akorn)), fluorometholone (fluorometholone acetate (Flarex® (Alcon),Eflone®), fluorometholone alcohol (FML® and FML-Mild®, (Allergan), FluorOP®), rimexolone (Vexol® (Alcon)), medrysone alcohol (HMS® (Allergan)),lotoprednol etabonate (Lotemax® and Alrex® (Bausch & Lomb), and11-desoxcortisol; an anti-prostaglandin such as indomethacin; ketorolactromethamine; ((±)-5-benzoyl-2,3-dihydro-1H-pyrrolizine-1-carboxylicacid, a compound with 2-amino-2-(hydroxymethyl)-1,3-propanediol (1:1)(ACULAR® Allegan), OCUFEN® (flurbiprofen sodium 0.03%), meclofenamate,fluorbiprofen, and the pyrrolo-pyrrole group of non-steroidalanti-inflammatory drugs; a macrolide such as sirolimus (rapamycin),pimocrolous, tacrolimus (FK506), cyclosporine (Arrestase), everolimus40-O-(2-hydroxymethylenrapamycin), ascomycin, erythromycin,azithromycin, clarithromycin, clindamycin, lincomycin, dirithromycin,josamycin, spiramycin, diacetyl-midecamycin, tylosin, roxithromycin,ABT-773, telithromycin, leucomycins, lincosamide, biolimus, ABT-578(methylrapamycin), and derivatives of rapamycin such as temsirolimus(CCI-779, Wyeth) and AP23573 (Ariad); a non-steroidal anti-inflammatorydrug such as derivatives of acetic acid (e.g. diclofenac and ketorolac(Toradol®, Voltaren®, Voltaren-XR®, Cataflam®)), salicylate (e.g.,aspirin, Ecotrin®), proprionic acid (e.g., ibuprofen (Advil®, Motrin®,Medipren®, Nuprin®)), acetaminophen (Tylenol®), aniline (e.g.,aminophenolacetaminophen, pyrazole (e.g., phenylbutazone),N-arylanthranilic acid (fenamates) (e.g., meclofenamate), indole (e.g.,indomethacin (Indocin®, Indocin-SR®)), oxicam (e.g., piroxicam(Feldene®)), pyrrol-pyrrole group (e.g., Acular®), antiplateletmedications, choline magnesium salicylate (Trilisate®), cox-2 inhibitors(meloxicam (Mobic®)), diflunisal (Dolobid®), etodolac (Lodine®),fenoprofen (Nalfon®), flurbiprofen (Ansaid®), ketoprofen (Orudis®,Oruvail®), meclofenamate (Meclomen®), nabumetone (Relafen®), naproxen(Naprosyn®, Naprelan®, Anaprox®, Aleve®), oxaprozin (Daypro®),phenylbutazone (Butazolidine®), salsalate (Disalcid®, Salflex®),tolmetin (Tolectin®), valdecoxib (Bextra®), sulindac (Clinoril®), andflurbiprofin sodium (Ocufen®), an MMP inhibitor such as doxycycline,TIMP-1, TIMP-2, TIMP-3, TIMP-4; MMP1, MMP2, MMP3, Batimastat (BB-94),TAPI-2,10-phenanthroline, and marimastat. The composition may containanti-VEGF agents such as ranibizumab (Lucentis®, Genentech) and/orpegaptanib (Macugen®). The composition may contain anti-PDGF agents suchas imatinib mesylate (Gleevec®) and/or anti-leukotriene(s) such asgenleuton, montelukast, cinalukast, zafirlukast, pranlukast, zileuton,BAYX1005, LY171883, and MK-571 to account for the involvement of factorsbesides VEGF in neovascularization. The composition may additionallycontain other agents including, but not limited to, transforming growthfactor β (TGFβ), interleukin-10 (IL-10), aspirin, a vitamin, and/or anantineoplastic agent.

The concentration of anti-inflammatory agent used in a particularembodiment may depend upon the particular class of agent (e.g., steroid,anti-prostaglandin, etc.), and/or particular agent (e.g., a lipophiliccompound versus a water-soluble compound), and/or its formulation (e.g.,extended release, delayed release, etc.), and/or its route ofadministration (e.g., intraocular injection versus systemicadministration), and/or patient specific variables (e.g., fast or slowmetabolizer, age, gender) etc. as will be appreciated by one skilled inthe art.

Examples of NSAIDs include, but are not limited to, derivatives ofacetic acid (e.g. diclofenac and ketorolac (Toradol®, Voltaren®,Voltaren-XR®, Cataflam®)); salicylate (e.g., aspirin, Ecotrin®);proprionic acid (e.g., ibuprofen (Advil®, Motrin®, Medipren®, Nuprin®));acetaminophen (Tylenol®); aniline (e.g., aminophenolacetaminophen;pyrazole (e.g., phenylbutazone); N-arylanthranilic acid (fenamates)(e.g., meclofenamate); indole (e.g., indomethacin (Indocin®,Indocin-SR®)); oxicam (e.g., piroxicam (Feldene®)); pyrrol-pyrrole group(e.g., Acular®); antiplatelet medications; choline magnesium salicylate(Trilisate®), cox-2 inhibitors (meloxicam (Mobic®)); diflunisal(Dolobid®), etodolac (Lodine®); fenoprofen (Nalfon®), flurbiprofen(Ansaid®); ketoprofen (Orudis®, Oruvail®); meclofenamate (Meclomen®);nabumetone (Relafen®); naproxen (Naprosyn®, Naprelan®, Anaprox®,Aleve®); oxaprozin (Daypro®); phenylbutazone (Butazolidine®); salsalate(Disalcid®, Salflex®); tolmetin (Tolectin®); valdecoxib (Bextra®);sulindac (Clinoril®); flurbiprofin sodium (Ocufen®).

Matrix metalloproteinases (MMPs) are zinc-dependent proteinase enzymesthat are associated with the tumorigenic process, and/or collagenases.These enzymes are used in the angiogenic process as well as in tumormetastasis and extracellular matrix (ECM) remodeling. Inhibitors ofmatrix metalloproteinases may include doxycycline and naturallyoccurring proteins such as the family of tissue inhibitors ofmetalloproteinases (TIMPs), such as TIMP-1 and TIMP-2 that are involvedwith the inhibition of angiogenesis and are capable of inhibiting tumorgrowth, invasion, and metastasis which has been related to MMPinhibitory activity; TIMP-3 which is found only in the extracellularmatrix; and TIMP-4 which may function in a tissue-specific fashion inextracellular matrix hemostasis; collagenase (MMP1) which degradesfibrillar interstitial collagens, gelatinase (MMP2) which mainlydegrades type IV collagen, and stromelysin (MMP3) which has a widerrange of action; and synthetic metalloproteinase inhibitors such asBatimastat (BB-94) and marimastat (BB-2516) which potently andspecifically inhibit metalloproteinase production. These inhibitorsdegrade the extracellular matrix, promoting tumor invasion andmetastasis, but also regulate host defense mechanisms and normal cellfunction. Selective inhibition is expected to inhibit reactions leadingto vascularization.

Various diseases and/or conditions can be treated with the method,including ARMD (wet or dry), diabetic macular edema, abnormal subretinalvessels caused by, e.g., previous histoplasmosis infection, etc.,dermatological conditions such as loose/wrinkled skin, and scaring, andvaricose veins, abnormal blood vessel formation in the skin, preventionof scarring, and cosmetic surgery. Tissues/cells at variousanatomic/physiologic sites in the body can be treated using thedisclosed method. Sites include, but are not limited to, eye, vessels,skin, mucous membranes, nose, ear, intestine, vagina, uterus, bladder,urethra, prostate, rectum, sinuses, brain, breast, heart, etc. Themanner in which the method is used to treat these sites is similar tothat described herein and is known by a person of ordinary skill in theart. As one example, body cavities such as the bladder or prostate maybe treated using an internal probe to provide a thermal effect at thetarget site; in embodiments where dye is added, it may be injectedsystemically or locally. As another example, skin may be treated usingan external device to provide a thermal effect at the target site; inembodiments where dye is added, it may be applied locally at the site.

ARMD is an angiogenesis-mediated ocular disorder in humans and is theleading cause of visual loss in individuals over age 55. There are twomajor clinical types of AMD: non-exudative or dry type, and exudative orwet type. A pathological complication of ARMD is choroidal angiogenesisor choroidal neovascularization (CNV). CNV is responsible for the suddenand disabling loss of central vision. In one embodiment, the methodcloses or treats choroidal vessels. The non-protein coagulationtemperature achieved using the method decreases the risk of damage tothe retinal vessels and therefore, treatment of choroidalneovascularization in ARMD is possible, while simultaneously protectingretinal vessels.

Macular edema may cause visual loss and legal blindness in patients withdiabetic retinopathy. Macular edema is the swelling of the retina due tofluid leaking from blood vessels within the macula. Diabetic macularedema is classified into focal and diffuse types. Focal macular edema iscaused by foci of vascular abnormalities, primarily microaneurysms, thattend to leak fluid. Diffuse macular edema is caused by dilatedcapillaries in the retina. The disclosed method reduces fluid leakageand/or promotes fluid reuptake.

Histoplasmosis is contracted by inhaling dust that carries the fungalspores. The fungus can affect the eye by causing small areas ofinflammation, retinal scarring, and development of abnormal bloodvessels. The disclosed method reduces and/or inhibits growth of theseabnormal vessels.

Dermatological conditions may be treated by the method. For example,cosmetic dermatological conditions such as wrinkles, loose skin,varicose veins, scars, etc. may be treated by the method.Thermotherapeutic effects may produce skin tightening, collagenproduction, closure of abnormal and/or leaky vessels, etc.

Varicose veins result from dilation and tortuosity of the superficialveins of the lower limbs. The result is discoloration, pain, swelling,and possibly ulceration of these veins. Varicose veins often involveincompetence of one or more venous valves, which allow reflux of bloodwithin the superficial system. This can also worsen deep venous refluxand perforator reflux. Current treatments of vein insufficiency includesurgical procedures such as vein stripping, ligation, and vein-segmenttransplant.

In one embodiment, the method's thermotherapeutic effect shrinks venoustissue and reduces vein diameter. Without being held to a single theory,this results in structural transfiguration of the collagen fibrils inthe vein, leading to shortened and thickened collagen fibrils inresponse to heat from thermal treatment.

The method will be further appreciated with respect to the followingnon-limiting examples.

EXAMPLE 1

Eye of individuals were treated using the disclosed method. In thistrial, 129 individuals, involving 150 eyes, were evaluated for 36 weeks;a long term study.

The individuals were diagnosed with clinically significant diabeticmacular edema based on Early Treatment Diabetic Retinopathy Studycriteria. Exclusions were previous pan-retinal or focal laserphotocoagulation, prior intraocular surgery or injection, history ofglaucoma or ocular hypertension, visual acuity (VA) of 20/40 or betteror worse than 20/300, presence of iris neovascularization, high riskproliferative diabetic retinopathy, significant lens opacity,monocularity, pregnancy, and serum creatinine ≧3 mg/dl.

Complete ophthalmic examinations were performed as a baselineassessment. Examinations included best-corrected VA, slit-lampbiomicroscopy, tonometry, and funduscopy. Para-clinic evaluations offundus photography, fluorescein angiography, and optical coherencetomography were performed. Best-corrected VA by the Snellen chart wasrecorded in logarithm of minimum angle of resolution (logMAR) scale.Lens opacity was graded from 0 to 4+ clinically. Optical coherencetomography mapping was performed using commercially available equipment(Zeiss, Dublin Calif.). Retinal thickness was measured in a circle (3.5mm diameter) centered on the fixation point. Mean thickness on a 1 mmcircle centered on the fovea, and central macular thickness (CMT) wasrecorded and considered for statistical analysis.

Eligible eyes were allocated to one of three study groups: eyesreceiving intravitreal bevacizumab injection alone (IVB group); eyesreceiving intravitreal bevacizumab injection plus intravitrealtriamcinolone (IVB/IVT group); and eyes undergoing macularphotocoagulation (MPC group). In bilateral cases, each eye was enrolledin the study individually; hence, both eyes of one patient could beallocated in one group.

Indications for retreatment were persistent clinically significantmacular edema if visual acuity was not better than 20/40. Retreatmentswere performed at 12-week intervals as required.

Injections were performed under restricted sterile condition, use ofanesthetic eye drops, and insertion of a lid speculum. For the IVBgroup, 0.05 mL (1.25 mg) bevacizumab (Avastin®; Genentech Inc., SouthSan Francisco Calif. (made for F. Hoffmann-La Roche Ltd., BaselSwitzerland) was injected intravitrally with a 27-gauge needle throughthe supratemporal quadrant. For the IVB/IVT group, in addition to theintravitreal bevacizumab injection, 0.05 mL (2 mg) of triamcinolone wasintravitrally injected with another 27-gauge needle through theinferotemporal quadrant. In bilateral cases, the injection in the secondeye was performed after two days. In the MPC group, standard focaland/or modified grid laser was performed.

Individuals who received injections were examined at 1 and 7 days afterinjections for anterior chamber reaction and to measure intraocularpressure. Complete ocular examination and optical coherence tomographywere performed again at 6, 12, 24, and 36 weeks. Fluorescein angiographywas repeated as needed. Blood pressure was measured initially and ateach visit.

The primary outcome measure was a change in best-corrected visual acuity(logMAR) at weeks 6, 12, 24, and 36. Secondary outcomes were CMT changesby optical coherence tomography and potential injection-relatedcomplications.

A sample size of 50 eyes for each group was required to have a 90% powerfor detection of 0.2 logMAR difference (equal to 2 Snellen lines) in themean VA among the groups as significant (at the two-sided 5% level),with an assumed standard deviation of 0.33.

Randomization was performed using a random block permutation methodaccording to a computer generated randomization list. The block lengthvaried randomly. Random allocation sequence was performed by abiostatistician. The study investigators did not know the detail ofseries.

For masking, a sham laser procedure (20 seconds) was performed in theIVB and IVB/IVT groups by aiming the laser beam on the macula. In theMPC group, a sham injection was done using a needleless syringe pressedagainst the conjunctiva. To maintain masking, individuals were preventedfrom seeing the syringes. All procedures were performed by staff otherthan the study investigators to preserve investigator masking.

Best-corrected VA measurement and OCT were performed by certifiedexaminers masked both to the randomization and to the results ofprevious measurements.

Statistical analysis was performed by SPSS software (version 15 SPSSInc., Chicago Ill.). For descriptive purposes, qualitative data werereported by percentage, and quantitative data were reported by mean±SD.To compare baseline data, the Chi-square test or Fisher's exact testwere used to evaluate qualitative data; analysis of variance (ANOVA) wasused to evaluate quantitative data.

The following proportions were used to describe the ratio of VA and CMTimprovement in each group at weeks 6, 12, 24, and 36: ((visual acuity atweeks 6, 12, 24, and 36)−(baseline visual acuity))/((baseline visualacuity)+(CMT at weeks 6, 12, 24, and 36)−baseline CMT))/(baseline CMT).

For comparing VA and CMT with baseline values within each group, apaired sample t-test was used. The marginal regression model, based onGeneralized Estimating Equation (GEE) methods, was used to compare VAand CMT in the treatment groups adjusted for the baseline values, aswell as to eliminate any possible correlation effects between the eyesof patients in bilateral enrolled cases.

P values less than 0.029 were considered statistically significant tocontrol the study-wise type 1 error (primarily type 1 error was set at0.05), based on an a spending function method (Pocock Clinical trials: apractical approach. Great Britain: John Wiley & Sons; 1990:148) for aninterim analysis.

The results were as follows: 150 eyes of 129 patients were enrolled andfollowed from September 2005 to May 2007. Mean age of patients±SD was61.2±6.1 years. Seventy nine patients (52.7%) were male. One hundredforty one (94%) eyes had nonproliferative diabetic retinopathy (NPDR)and 9 eyes (6%) had early proliferative diabetic retinopathy.

Eyes were randomly assigned to one of the treatment groups: (1) 50 eyesin the IVB group; (2) 50 eyes in the IVB/IVT group; and (3) 50 eyes inthe MPC group. Retreatment was required for 27 eyes up to 36 weeks; 14eyes in the IVB group, 10 eyes in the IVB/IVT group, and 3 eyes in theMPC group. Third repeated treatment was required in 3 eyes in the IVBgroup, 3 in the IVB/IVT group, and 1 in the MPC group.

Means and proportions of improvement of the corrected VA and CMT in eachgroup at every visit were obtained (data not shown). Comparisons wereperformed after adjustment of the parameters according to their baselinequantities in order to compensate for the influence of dissimilarbaseline VA and CMT on the results.

Comparing to the baseline, VA improvement was significant in the IVBgroups at all follow up visits up to 36 weeks (P<0.001). In the IVB/IVTgroup, VA improved significantly only at weeks 6 and 12 (P=0.002 and0.019, respectively). In the MPC group, however, VA changes in relationto the baseline did not change significantly.

In the marginal regression model, the GEE analysis demonstrated that thedifferences in VA changes among the groups were statisticallysignificant only at 6 and 24 weeks (P<0.001 and P=0.012, respectively).Pairwise comparison between groups showed that the VA improvement at 6weeks in both IVB and IVB/IVT groups was better than the MPC group(P<0.001); however, there was no significant difference between the IVBand IVB/IVT groups (P=0.199). At 24 weeks, pairwise comparison showedthat the difference of VA changes between the IVB and MPC groups wassignificant in favor of the IVB group (P=0.003). This difference betweenthe IVB/IVT and MPC groups was borderline (P=0.033). However, nosignificant difference between the IVB and IVB/IVT groups was observed(P=0.373). At 12 and 36 weeks, VA improvement was greater in the IVBgroup than the other groups, although the results were not significant.

To evaluate the effects of different applied treatments on Snellen VA,the percentages of eyes with more than 2 lines VA improvement werecompared. Eyes with stable VA (within 2 lines changes), and eyes withmore than 2 lines VA declined among the groups. Overall, the percentageof eyes with stable VA was relatively similar among the groups at allfollow-ups. The percentage of cases that gained more than 2 Snellenlines was more in the IVB and IVB/IVT groups than in the MPC group. Thepercentage of eyes that lost more than 2 Snellen lines was higher in theMPC group than the other groups. These differences were statisticallysignificant among the groups at 6, 12, and 24 weeks.

CMT decreased significantly in all groups, compared to baseline, only at6 weeks. The CMT reduction was greater in the IVB group in relation tothe other two treatment groups, although the differences were notsignificant at any follow up time.

In the marginal regression model, generalized estimating equationanalysis showed no statistically significant difference in CMT changesamong the three groups at any follow up time.

VA and CMT changes of these patients were compared with patients havingcomplete data, in order to eliminate any possible bias regarding caseswith missing data at any of the follow up visits. There was nosignificant difference.

Transient anterior chamber reaction (trace to 1+ cell) was observed in10 (20%) and 9 (18%) eyes in the IVB and IVB/IVT groups, respectively.This side effect resolved spontaneously after one week in all groups.Ocular hypertension (≧23 mmHg) was detected in 8 eyes (16%) of theIVB/IVT group; it was controlled in all eyes by medical therapy, exceptin one eye that progressed to neovascular glaucoma. Severe lens opacitydeveloped in 5 eyes; 4 in the IVB/IVT group and 1 in the MPC group.Initially, retinal neovascularization was observed in 4, 2, and 3 eyesin the IVB, IVB/IVT, and MPC groups, respectively. All but one of theseneovascularizations were resolved; the one neovascularization was in theMPC group. Eight eyes developed early proliferative diabetic retinopathyduring the study period (1 in the IVB group; 4 in the IVB/IVT group; 3in the MPC group). These eyes remained stable during the follow upperiod. Ten eyes progressed to high-risk proliferative diabeticretinopathy (4 in the IVB group; 3 in the IVB/IVT group; 3 in the MPCgroup). These eyes were treated accordingly and excluded from the study.

No significant increases in blood pressure, thromboembolic events, andocular complications such as vitreous hemorrhage, endophthalmitis, andretinal detachment were detected during the study. Four patients (5eyes) passed away during the course of the trial; 2 in the IVB/IVTgroup; 2 in the MPC group.

A statistical adjustment was performed to lessen the effect ofinadvertent substantial imbalance in baseline VA and CMT in the groups.Statistical methods could not always overcome the problem of unequaldistribution of the factors among groups. No subgroup analysis such asmild versus moderate visual loss, or focal versus diffuse macular edema,was performed according to the initial characteristics of DME.

This three-arm randomized clinical trial demonstrated superiority ofintravitreal injection of bevacizumab, either alone or in combinationwith triamcinolone acetonide, over macular laser photocoagulation in VAimprovement in primary treatment of diabetic macular edema (DME). Thisimprovement persisted longer in the IVB group (up to 36 weeks) comparedto the IVB/IVT group (up to 12 weeks). In the MPC group, no VAimprovement was observed at any follow-up visit. Concerning CMTreduction, there was no meaningful superiority of the IVB and IVB/IVTgroups over the MPC group. Significant CMT reduction relative tobaseline measurement was observed in all groups only at 6 weeks. Theprimary treatment of DME, triamcinolone acetonide, not only did not haveany additive effect over bevacizumab, but also resulted in lessfavorable visual outcome in the combined treatment group.

Considering the key role of VEGF in the pathophysiology of diabeticretinopathy, VEGF blockade is an attractive therapeutic approach.Bevacizumab is a pan-VEGF blocking agent and may impair normalphysiologic VEGF-mediated functions. While one might consider this as adisadvantage, its popularity, availability, and reasonable cost causedus to include it in this clinical trial.

The beneficial effect of IVB on patients with DME has been demonstratedin recent published studies, including the preliminary results of thepresent clinical trial. In a phase-II study, Diabetic RetinopathyClinical Research Network (DRCRN) disclosed a median I-line improvementat 3 weeks that was sustained through 12 weeks by two injections ofeither 1.25 mg or 2.5 mg IVB. The instant study demonstrated an almost0.3 logMAR improvement in mean VA (about 3 Snellen lines), persistingfor 36 weeks. The majority (72%) of cases in the instant study requiredonly one IVB injection during the study period. Similar to our study,the DRCRN study also demonstrated inferiority of MPC compared to IVB.The DRCRN study also clarified that CMT reduction following IVB at 3weeks appeared to plateau or decrease in most eyes between 3- and 6-weekvisits. This result was comparable to our results showing a diminishingeffect on CMT after 6 weeks. In the DRCRN study, it was suggested that 6weeks might be too long for an optimal second-injection interval.However, the instant study demonstrated that the therapeutic effect of asingle IVB injection may persist for up to 36 weeks for VA improvement.This improvement, without a significant decrease in CMT, may beexplained by increased macular perfusion rather than leakage reductionand/or fluid resorption. It has been shown that VA changes are notalways parallel to CMT changes in DME.

The effective period for IVB in treating DME was reported to be 6 weeksand 12 weeks. The Pan-American Collaborative Retina Study Group reportedthat 20.5% of their cases required a second injection, and 7.7% of theircases required a third injection within 6 months. In the instant study,similarly, 22% and 6% of eyes required a second and third injection,respectively. These repeated injections of VEGF inhibitors may causeretinal atrophy by blocking neuroprotective cytokines. Therefore,routine prescheduled repeated injections may not be appropriate in theprimary treatment of patients with DME. The decision for re-treatmentshould be individualized in each patient.

A recent pilot study reported the short-term beneficial effect ofintravitreal ranibizumab therapy for improving VA and reducing CMT inpatients with DME. Comparison among efficacy endpoints of pegaptanib,ranibizumab, and bevacizumab in DME was limited by differences in studysize, study design, inclusion/exclusion criteria, drug dosage, and drugadministration schedule.

Few prospective, randomized studies have evaluated the effect ofintravitreal injection of triamcinolone on DME. From their 2-year studyresults, Gillies et al. (Ophthalmology 113 (2006) 1533) concluded thatrepeated IVT injections improved vision and reduced CMT in eyes withrefractory DME. To enhance therapeutic effects, the instant studycombined injection of IVB with IVT. No additive effects of IVT in termsof VA improvement and CMT reduction were observed. VA improvement in theIVB/IVT group lasted less than that of the IVB group (12 weeks versus 36weeks). Without being bound by a single theory, lens opacityprogression, ocular hypertension, and adverse effects of triamcinolonepreservatives might be the causes for this observation. Addition oftriamcinolone did not result in increased reduction in CMT in theinstant study. In a recent published comparative case series on 28 eyesof 14 patients (Shimura et al, Am J Ophthalmol 145 (2008) 854), IVT (4mg) was better than IVB in reducing CMT and improving VA. Consideringthe results of this study and the instant study, one may conclude thatinjection of either IVB or IVT alone has a better outcome than combinedtreatment. In Shimura's study, 16 out of 28 eyes had undergonepan-retinal photocoagulation, and 18 out of 24 eyes had a history ofcataract surgery before intervention. Both of these factors wouldincrease the inflammatory response and might explain the greaterreported effect of triamcinolone; both of these factors were amongexclusion criteria in the instant study.

In the instant study, 2 mg triamcinolone (instead of the usual dosage of4 mg), was injected first to diminish the side effects of the drug andthen to avoid having a total volume of intravitreal injection >0.1 ml,which might necessitate anterior chamber paracentesis. The optimaldosage of intravitreal triamcinolone is debatable; most researchersrecommend 4 mg triamcinolone for intravitreal injection, but recentlyAudren et al. (Am J Ophthalmol 142 (2006) 794) compared efficacy andsafety of intravitreal injection of 2 mg, versus 4 mg, triamcinolone fortreatment of DME, and noticed no dose differences. It has been shownthat even with lower volumes of injected triamcinolone, corticosteroidreceptors inside the eye become saturated.

An early treatment diabetic retinopathy study (ETDRS) trial showed thatfocal MPC decreased the rate of moderate visual loss in eyes withclinically significant macular edema. Lee and Olk (Ophthalmology 98(1991)1594) demonstrated that 24.6% of eyes with diffuse DME lost threeSnellen lines or more with modified grid MPC. With this treatment, only14.5% of cases experienced vision improvement. In the instant study,mean VA did not change significantly up to 36 weeks after macularphotocoagulation. VA improvement >2 Snellen lines at 36 weeks wasobserved in 37.0%, 25.0%, and 14.8% of the IVB, IVB/IVT, and MPC groups,respectively. Thus, considering the potential side effects of MPC suchas transient increased macular edema, paracentral scotoma, subretinalfibrosis, and inadvertent foveolar burns, intravitreal bevacizumab maybe preferred for primary treatment of DME compared to MPC. Although thecombination of IVB and MPC may have an additive effect, this has notbeen proven in the short term by DRCRN. DRCRN recently demonstrated thatMPC was more effective and incurred fewer side effects than IVT over atwo year period for most patients with DME, although in the short term,VA was better in the IVT group. Therefore, with longer follow up, morebeneficial effects of MPC may have emerged in the instant study.

Regression of retinal neovascularization was observed in 6% of eyes inboth intravitrally-injected groups, and 4% of the eyes in the MPC group,in the instant study. Progression to early proliferative diabeticretinopathy was observed in 5% and 6%, and to high-risk proliferativediabetic retinopathy in 7% and 6%, respectively, in theintravitrally-injected groups and the MPC group. Retinalneovascularization regression in eyes with proliferative diabeticretinopathy in association with intravitreal bevacizumab treatment hasbeen reported. No significant differences in neovascularizationregression and progression rates observed among the groups in theinstant study may be due to the low number of cases showing such events.

No hypertension, thromboembolic events, and major intravitrealinjection-related complications were encountered in the instant study.Ocular hypertension 23 mmHg) was observed in 8 eyes (16%) of the IVB/IVTgroup, and was controlled by anti-glaucoma medication except in one eyethat progressed to neovascular glaucoma. Mild anterior chamber reactionoccurred one day after injection in 20% and 18% of eyes, respectively,in the IVB and IVB/IVT groups; it spontaneously resolved within oneweek.

For patients presenting with DME for the first time, MPC is currentlythe standard treatment, but may not be ideal. The instant study comparedlong-term effect of bevacizumab, alone and with triamcinolone, versuslaser macular photocoagulation in treatment of DME. Compared with MPC,intravitreal injection of bevacizumab effectively increased VA or up to36 weeks, although its effect on decreasing retinal edema was transient.In 72% of eyes, this long-term beneficial effect persisted up to 36weeks even with a single bevacizumab injection. No additive effect oftriamcinolone was observed Based on these results, intravitrealinjection of bevacizumab alone may be an alternative or even first linetreatment in such cases.

EXAMPLE 2

A diode laser producing 870-810 nm radiation was used in the oscillatorymode as an energy source. A slit lamp was used for illuminating thefundus and delivering laser light. Topical anesthesia was used, insteadof subconjunctival, peribulbar, or retrobulbar anesthesia, so thepatient was able to communicate pain sensation experienced during theinitial test application.

A test spot was used initially to determine pain level. The test spotwas applied using stationary light to a peripheral area of the retina;the energy was not sufficient to produce coagulation. Light applicationwas stopped if the patient experienced pain. The time of lightapplication was usually between 10 seconds to 30 seconds. If painoccurred within 1 second to 10 seconds of application, the light energywas reduced by 50 mW increments to achieve the desired level. Thisenergy level, or a slightly lower level, e.g. 50 mW lower level, wasthen used in an oscillatory mode over the fovea. A mechanical handcontrolled oscillation mechanism was used with about 1 oscillation/secto about 5 oscillation/sec. ICG at a dose of 25 mg/2 ml wasintravenously injected after initiating OTT.

Each of the figures were photographs obtained using optical coherencetomography (OCT) of the macula. Preoperative photographs show a swollenretina. Post operative photographs show decreased edema and fluid lossin the retina (macula).

FIG. 1 is from patent 1 (DG), a 48 year old male with choroidalneovascularization from histoplasmosis who had received a number ofprevious treatments including PDT×2, multiple TTT, multiple intravitrealinjections of steroids and bevacizumab with no response. He then wastreated with OTT twice with concurrent intravitreal dexamethasone on thesame day. These treatments resulted in regression of the choroidalneovascular membrane regressed (FIG. 2). Since the last visit, he hasmaintained 20/30 vision.

FIG. 3 is from patient 2 (CR), a 69 year old female with a peripapillarychoroidal neovascular membrane. Patient 2 failed previous treatments andthus was treated with oscillating TTT. Treatment parameters were 1.2 mmspot size, 200 mW power, and 90 second duration with concurrentintravitreal dexamethasone administered on the same day. Thesetreatments resulted in OCT showing significant reduction in edema andexudates (FIG. 4).

FIG. 5 is from patient 3 (KJ), a 52 year old female with choroidalneovascularization from histoplasmosis who had previously been treatedwith laser photocoagulation, PDT and anti-VEGF agents. Patient 3developed a stroke after one of the anti-VEGF treatments. The choroidalneovascularization recurred with vision of 20/50 and metamorphopsia.Patient 3 received one oscillating TTT treatment. Treatment parameterswere 0.5 mm spot size, 200 mW power, and 60 second duration withconcurrent intravitreal dexamethasone administered on the same day.About one week later, patient 3 returned with decreased vision of 20/200(FIG. 6). OCT showed increased macular edema; edema and decreased visionresolved in one week 20/30 visions (FIG. 7). Metamorphopsia resolvedwith vision stabilization, but about one month later patient 3 developeda recurrence and was recently treated with intravitreal steroids andmethotrexate.

FIG. 8 is from patient 4 (AH), a 90 year old male with advancedbilateral exudative macular degeneration. Patient 4 failed previoustreatments including intravitreal bevacizumab. Patient 4 received oneOTT treatment in the left eye. Treatment parameters were 2.0 mm spotsize, 400 mW power, and 60 seconds duration with concurrent intravitrealbevacizumab administered on the same day. Patent 4 had anatomicimprovement, with resolved fluid and hemorrhage (FIG. 9). Patient 9'sdisease was very advanced with central scarring, so there was noimprovement in vision.

FIG. 10 is from patient 5 (AF), an 80 year old diabetic female referredfor significant bilateral macular edema of both eyes. Visual acuity inthe right eye varied between 20/80 and 20/300. Baseline OCT of the righteye showed severe intra- and sub-retinal fluid. The central macularthickness was 396 OD, which was likely due to DME. Patient 5 receivedone oscillating TTT treatment to the right eye, with intravenous ICG ata follow-up appointment on day 10 after TTT treatment. At the follow-upappointment, the edema had nearly complete resolution, and the OCTshowed a normal thickness of 179 μm (FIG. 11), and VA was 20/80.

FIG. 12 is also from patient 5 (AF). Baseline OCT of the left eye showedsevere intra and sub-retinal fluid with a central macular thickness of477 OS, which is likely due to DME along with a dry form of ARMD havingsoft drusen. Patient 5 received one treatment of oscillatingtranspupillary therapy in the left eye. After the follow-up appointment,there was nearly complete resolution of edema in the left eye. The OCTshowed a normal thickness of 187 microns (FIG. 13) and the VA improvedas well to 20/100.

All references cited are incorporated by reference herein in theirentirety. Other variations or embodiments will also be apparent to oneof ordinary skill in the art from the above description and examples.Thus, the foregoing embodiments are not to be construed as construed aslimiting the scope of the following claims.

1. A method for determining an energy level to apply to an ocular tissuetarget site of a patient to be treated by thermotherapy, the methodcomprising the steps of (a) exposing the patient to an energy level thatis the maximum energy level applied to an ocular target site duringthermotherapy and the temperature reached in the ocular target tissueupon exposure to less than or equal to the energy level is greater thanbody temperature and less than a temperature at which proteindenaturation is initiated in the ocular tissue, (b) determining theenergy level to be applied to the ocular target tissue based on thepatient's response indicating the subjective experience of a sensationof pain at the time the patient expresses the sensation of pain, and (c)thereafter applying up to the energy level determined in (b) to anocular tissue target site for thermotherapy.
 2. The method of claim 1where the patient's response is verbal.
 3. The method of claim 1resulting in precluding exposing the patient to a temperature at whichproteins denature during thermotherapy.